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www.pcmch.on.ca

ED Clinical Pathway for Children and

Youth with Mental Health Conditions

Implementation Toolkit September 2013

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Objective of this learning module

To educate physicians, clinicians and mental health service providers about:

1. The Emergency Department (ED) clinical pathway for

children and youth with mental health conditions.

2. The assessment tools in the clinical pathway.

3. Use of a memorandum of agreement to support a

seamless transition between hospital and community

mental health providers.

• Estimated 14-21% of Canadian children / youth

suffer from mental health and/or addiction

(MH/A) disorders.

• Youth aged 15 to 24 • 3 X more likely to have substance use problem than >24 years

• More likely to experience mood disorders such as anxiety and

depression.

Background I

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Background II

High demand for Emergency Mental Health care • ED is a frequent entry point for child & youth mental

health/addictions (CY MH/A) services

• In 2009-2010, 19,582 ED visits by children and youth in Ontario

had a MH/A diagnosis.

Background II

High demand for Emergency Mental Health care

Limited ED capacity to respond to CY MH/A needs • Organized chaos

• Acute care, diagnosis and management focus

• Mental health expertise …

Background II

High demand for Emergency Mental Health care

Limited ED capacity to respond to CY MH/A needs

Challenge of smooth and streamlined integration with

community CY MH/A services • Ministry of Health: ED care

• Ministry of Child & Youth Services: Mental Health Agencies

Currently, MH/A services in Ontario are funded or

provided by at least 10 different ministries.

Community care is delivered by 440 children’s

mental health agencies, 330 community mental

health agencies, and 150 substance abuse

treatment agencies.

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Scope of the Clinical Pathway

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Due to the limited resources

currently available to support the

needs of children and youth with

addictions, this clinical pathway

will focus only on the needs of

children and youth with mental

health concerns.

To guide and support care of children and youth, 17 years of age and younger, presenting to EDs with mental health concerns.

To ensure seamless transition to follow-up services with relevant community mental health agencies and providers.

Clinical Pathway: Purpose

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• Support decision making

• Communication tool

• Support delivery of high quality care

• Support evidence informed practice

• Support interdisciplinary care

• Improve outcomes

• Improved utilization of resources

Benefits of Clinical Pathways

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ED Clinical Pathway for MHC

Minimum Standards

The following standards of care are required to

ensure effective implementation of the ED CP:

1. Access to child and youth mental health clinician

(CY MH clinician)

2. Memorandum of agreement between EDs and

community providers and agencies

3. Use of standardized triage screening tools

Minimum Standards of Care

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ED Clinical Pathway for MHC

CY MH Clinician

Child and Youth Mental Health Clinician

• Skills and focus to assess MH patients in ED

• Crisis services are main link to appropriate and

timely referral to community MH services

Recommendation:

• Every accredited hospital ED should have 24/7

access to child and youth mental health clinician • Not limited to in-person/on-site consultation

• Community/mobile service, telephone or video access

CY MH Clinician

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CY MH Clinician: Roles

• Collaborate with ED team in assessment, treatment

and discharge plans

• Provide specific clinical interventions as required

• Collaborate with Community MH agencies to ensure

appropriate referrals and timely patient access

• Key role in ensuring integration of services: • ED and community MH agencies

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• Masters of Social Work (MSW), Bachelor of Social

Work (BSW), Psychological Associate (C.Psych.

Assoc), or Registered Nurse (RN)

+ Registration/eligibility with their professional college.

• When this is not available: • Child & Youth Worker Diploma (3 year program), or B.A. in

Child & Youth Care, if relevant experience.

• Must have knowledge of child and youth psychiatric disorders

and minimum 3 years counseling experience

CY MH Clinician: Competencies

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ED Clinical Pathway for MHC

Memorandum of

Agreement

Between

Emergency Department

And

Community Mental Health

Agencies

Memorandum of Agreement (MOA)

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• Key component for pathway success

• Among ED & Community Agencies • Comprehensive understanding of pathway and roles within it.

Recommendation: • Implementation of an MOA between all parties involved to

ensure collaboration and adherence to ED MH CP

MOA: Purpose

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• Statement of purpose • Governing principals • Details regarding the parties to the MOA • Details of the process to be followed • Information sharing and privacy details • Leadership details

MOA: Key Components

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ED Clinical Pathway for MHC

Clinical Pathway (CP)

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Recommendation:

• Standardized assessment form that is shared

with the MH community agency upon discharge

• Follows the patient

• Shared branding

• Confidentiality—HIC inclusive

• Enables physicians to take a psychosocial

history which aids in decisions regarding patient

disposition. Includes 7 variables.

Standardized Assessment

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ED Mental Health Clinical Pathway

Standardized Assessment Form – page 1

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ED Mental Health Clinical Pathway

Standardized assessment form – page 2

HEADS-ED Tool

Clinical Pathway (CP) Algorithm

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• The entry point for the algorithm is the ED triage

• Initial assessment by an experienced ED nurse

with special triage training and experience

• The Canadian Triage Acuity Scale (CTAS)

guidelines are used to assign each patient to the

appropriate priority level for assessment

• Specific MH problems are addressed in the CTAS

guidelines

CP Stage: ED Triage

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• The patient is taken immediately to appropriate

ED area for assessment and management.

• If medically stable, the patient may then be

directed for MH assessment, if appropriate, as

per the algorithm. Only a small proportion of

patients require this type of immediate care.

CP Stage:

Resuscitative / Emergent Care

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All medically stable patients will be asked to complete a

set of self-report surveys.

• All patients or caregivers: complete the Caregiver or

Youth Perception Survey (C/YPS)

• Patients 10-21 years of age: complete the Ask Suicide

Screening Questions (ASQ)

• Patients under 12 years: caregivers complete the

Pediatric Symptom Checklist (PSC)

• Patients ≥ 12 years: complete the Global Appraisal of

Individual Needs—Short Screener (GAIN-SS).

CP Stage: Mental Health Screening

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• Depending on resources available, patients will either:

• First be assessed by an ED physician, and then be

referred to a Child and Youth Mental Health Clinician

(CY MHC) for further assessment, or

• Be assessed directly by a CY MHC

• Patients deemed high risk by the CY MHC would be

reviewed for potential admission with the Psychiatrist,

Pediatrician or Family Physician on call, as available

based on arrangements at that site.

CP Stage: Clinical Assessment

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Based on clinical assessment(s), one of three

disposition decisions will be made:

1. Immediate referral to a mental health (MH) specialist with

potential admission

2. Outpatient referral to a CY MH community agency • Telephone follow up in i) 24 hours or ii) within 7 days

3. Disposition home • Recommended follow-up with Primary Care provider

• Provision of contact/resource information for relevant

community MH services

CP Stage: Disposition

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Referrals to CY MH Community Agencies:

• Expectation for telephone follow-up is to review

the presenting concerns and ED referral

information and to determine priority for the in-

person assessment at that agency.

• Expectation that the community agency inform the

ED of this follow-up outcome, should the

child/youth re-present to the ED.

CP Stage: Disposition Continued

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ED Clinical Pathway for MHC

Screening Tools

• Very Brief

• Very Easy to complete

• Very Easy to score

• Clinically intuitive

• Help guide clinical decisions in assessment and

disposition recommendations

Optimal MH Risk Assessment Tool

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Screening Tool

All CY MH

patients

CY MH patients aged:

Available in public

domain free of charge

Children’s Hospital of Eastern Ontario (CHEO) Caregiver/Youth Perception Survey (C/YPS)

Yes

Ask Suicide Screening Questions (ASQ)

10-21 years

Yes

Paediatric Symptom Checklist (PSC)

<12 years Yes

Global Appraisal of Individual Needs – Short Screener (GAIN-SS)

≥12 years No PCMCH is

purchasing the license

HEADS-ED Tool Yes

MHC Screening Tools for C&Y

• Initial Screen:

• CHEO Youth/Caregiver Perception Survey (Y/CPS)

• Ask Suicide Screening Questions (ASQ)

• In-Depth Screen:

• Paediatric Symptom Checklist (PSC)

• GAIN Short Screener (GAIN-SS)

• Clinical Risk Assessment Tool:

• HEADS-ED

MHC Screening Tools for C&Y

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CHEO Youth / Caregiver Perception

Survey (Y/CPS)

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• A general MH/A screening tool used that

addresses presenting concerns and stress

factors in the child/youth’s life.

• For use with all children/youth with MH

concerns presenting to the ED

Validation Information

• Difficult to evaluate using traditional psychometric

techniques

• Have face and content validity from both the

clinician and patient/caregiver perspectives

CHEO Y/CPS

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Caregiver Perception Survey (CPS)

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Youth Perception Survey (YPS)

• A four item questionnaire specifically

indicated for use in the ED to detect children

and youth at risk for suicide

• For CY MH/A patients 10-21 years

• For use by non-psychiatric clinicians

• Positive screen: “Yes” to any question

Ask Suicide-Screening Questions

(ASQ)

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Validation Information

• Sensitivity of 0.97

• Specificity of 0.88

• Negative predictive value for psychiatric patients:

0.97

ASQ

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ASQ

• An in-depth psychosocial screen designed to

facilitate the recognition of cognitive,

emotional and behavioural problems.

• Questions include internalizing, attention and

externalizing problems.

• For all CY MH/A patients under 12 years

Pediatric Symptom Checklist

(PSC)

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Validation Information

• Well validated across several studies

• Sensitivity of 0.95 and Specificity of 0.68

• High internal consistency, high reliability

PSC

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Pediatric Symptom Checklist (PSC)

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Pediatric Symptom Checklist (PSC)

• An in-depth MH screen targeted for

adolescents. It identifies internalizing disorders,

externalizing disorders, substance use and

crime/violence.

• For all CY MH patients 12 years or age and

older

• Requires a user licence which PCMCH will

obtain. The GAIN-SS will be available for

download from the PCMCH website.

Global Appraisal of Individual

Needs—Short Screener (GAIN-SS)

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Validation Information

• Well validated across several studies

• Sensitivity of 0.91and Specificity of 0.90

• High internal consistency when compared with the full GAIN

Findings

• Low risk: 0 past year symptoms

• Moderate risk: 1-2 past year symptoms

• High Risk: 3+ past year symptoms

GAIN-Short Screener

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Global Appraisal of Individual Needs- Short Screener (GAIN-SS)

PCMCH will purchase

the license.

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Global Appraisal of Individual Needs- Short Screener (GAIN-SS)

PCMCH will purchase the

license.

• Help guide clinical decisions in assessment and

disposition recommendations • Very Brief

• Very Easy to complete

• Very Easy to score

• Clinically intuitive

• 7 variables rated on a 3-point scale, based on

need for action

The HEADS-ED Tool

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CHEO study with the HEADS-ED

• Crisis workers completed the HEADS-ED and CANS

• Youth completed the Children’s Depression Inventory

• Evidence of inter-rater reliability, and criterion, concurrent and predictive

validity for HEADS-ED

• The HEADS-ED correlated highly with youth’s ratings of depression and

a comprehensive clinician rating of mental health strengths and needs.

• The tool had good detection of indicators of admission to inpatient

psychiatry.

HEADS-ED tool does not replace best clinical judgement;

should be used to assist in clinical decision making.

Evidence for HEADS-ED

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HEADS-ED Website: www.heads-ed.com

• Simple interface to enter HEADS-ED scores

• Generates list of community resources (currently in

Champlain LHIN only) based on patient’s age,

language, and needs according to the HEADS-ED

• Provides customized printout of resources for

patients/families, including personalized discharge

instructions and HEADS-ED score summary

HEADS-ED Capability

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HEADS-ED Tool

0No action

needed

))))))))))

1Needs action

but not

immediate

2Needs

immediate

action

Home ○○ Supportive ○○ Conflicts○○ Chaotic /

dysfunctional

Education ○○ On track○○ Grades dropping /

absenteeism○○ Failing / not

attending school

Activities & peers ○○ No change○○ Reduced / peer

conflicts

○○ Fully withdrawn /

significant peer

conflicts

Drugs & alcohol ○○ No or infrequent ○○ Occasional ○○ Frequent / daily

Suicidality ○○ No thoughts ○○ Ideation ○○ Plan or gesture

Emotions, behaviours,

thought disturbance

○○ Mildly anxious /

sad / acting out○○ Moderately

anxious / sad /

acting out

○○ Significantly

distressed / unable

to function / out of

control / bizarre

thoughts

Discharge resources○○ Ongoing / well

connected○○ Some / not

meeting needs○○ None / on wait list

/ non-compliant

0No action

needed

))))))))))

1Needs action

but not

immediate

2Needs

immediate

action

Home ○○ Supportive ○○ Conflicts○○ Chaotic /

dysfunctional

Education ○○ On track○○ Grades dropping /

absenteeism○○ Failing / not

attending school

Activities & peers ○○ No change○○ Reduced / peer

conflicts

○○ Fully withdrawn /

significant peer

conflicts

Drugs & alcohol ○○ No or infrequent ○○ Occasional ○○ Frequent / daily

Suicidality ○○ No thoughts ○○ Ideation ○○ Plan or gesture

Emotions, behaviours,

thought disturbance

○○ Mildly anxious /

sad / acting out○○ Moderately

anxious / sad /

acting out

○○ Significantly

distressed / unable

to function / out of

control / bizarre

thoughts

Discharge resources○○ Ongoing / well

connected○○ Some / not

meeting needs○○ None / on wait list

/ non-compliant

HEADS–ED

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ED Pathway for MHC

Pre-printed Order Set

Practice Recommendations

Use of pre-printed order sets ensure standardized,

evidence-based management practices.

Recommendation: PPO for chemical restraint to be

implemented within the ED MH

Clinical Pathway, to be used as

needed

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Pre-printed

Order Set:

Chemical

Restraint in

the ED

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Summary

The development of an ED CY MH

clinical pathway will promote safe

and integrated services for children

and youth with mental health

concerns through efficient risk

assessment and timely follow-up.

This will provide better patient care

and reduce unnecessary use of

costly emergency services.

www.pcmch.on.ca

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